- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $443.49 / $443.49 / $1,822.74
| Facility | | $443.49 | $443.49 | $1,822.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $830.91 / $830.91 / $995.52
| Professional | | $830.91 | $830.91 | $995.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $504.89 / $682.29 / $1,146.25
| Facility | | $504.89 | $682.29 | $1,146.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $286.56 / $286.56 / $1,023.44
| Professional | | $286.56 | $286.56 | $1,023.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $286.56 / $286.56 / $436.67
| Professional | | $286.56 | $286.56 | $436.67 |